Provider Demographics
NPI:1639683493
Name:BERNHARDT, GEORGE KARL (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:KARL
Last Name:BERNHARDT
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4534 N WILSON DR APT 4
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:53211-1346
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1111 E DELAFIELD RD
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-8673
Practice Address - Country:US
Practice Address - Phone:262-560-3505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-30
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2069-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer